HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure walls were smoke resistant and failed to ensure structural beams had 1-hour fire retardant coating in 5 of 6 smoke compartments. The findings were:

1. Observation on 5/15/12 between 10 AM and 11:30 AM showed there were unsealed wall penetrations in the following locations:
a. Secure storage #815
b. Theater storage closet #609c
c. The car port
The largest gap measured 3 inches across with a total of 8 unsealed penetrations. On 5/15/12 at 10:13 AM the lead electrician reported the security staff completed monthly inspections and reported findings to the maintenance department. He could not explain why the aforementioned penetrations had not been noticed and reported to the maintenance department.

2. Observation on 5/15/12 between 11 AM and 12 PM showed roof steel I-beams above the mail room and electrical room had the 1-hour rated flame retardant material missing. The largest exposed section of beam measured 8 inches by 24 inches. On 5/15/12 at 1:47 PM the lead electrician reported he was aware of the flame retardant material falling off beams throughout the building, but the facility had not made any effort to replace the product.

Based on observation and staff interview, the facility failed to ensure 1 of 5 smoke barrier walls was smoke resistant. The findings were:

Observation on 5/15/12 at 11:34 AM showed the smoke barrier wall above the south clinical entrance double doors had a ? inch unsealed gap. At the time of the observation the lead electrical could not explain why the penetration had not been noticed and filled during the annual inspection.

Based on observation and staff interview, the facility failed to ensure hazardous areas were separated from use areas in 1 of 6 smoke compartments. The findings were:

Observation of mechanical room #706 on 5/15/12 at 10:28 AM showed there were three unsealed wall penetrations. The largest gap measured 3 inches across. At the time of the observation the lead electrician reported the security staff completed monthly inspections and reported findings to the maintenance department. He could not explain why the aforementioned penetrations had not been noticed and reported to the maintenance department.

Based on observation and staff interview, the facility failed to ensure the emergency generator was equipped with a remote emergency stop button. The findings were:

Observation of the emergency corridor lights showed they were supplied with power from the emergency generator. Observation of the generator on 5/15/12 at 10:34 AM showed it was not equipped with an emergency stop button outside of the weather proof enclosure. At the time of the observation the lead electrician reported the generator was installed in 1999. He was unaware generators have required emergency stop buttons since 1983.

Reference, NFPA 101, 2000 Edition, 19.2.9.1, 7.9.2.3, NFPA 110, 1999 Edition;
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

Based on observation and staff interview, the facility failed to ensure sprinkler heads were installed in the proper orientation in 1 of 2 smoke compartments. The findings were:

Observation of cooler #9 on 5/15/12 at 2:13 PM showed two sidewall sprinkler heads were installed in pendant locations. At the time of the observation the lead electrician reported he was aware sprinkler heads are required to be installed in the proper orientation. He could not explain why these heads had not been noticed during the 11/14/11 annual inspection and replaced with pendant heads.

Reference, NFPA 101, 2000 Edition, 13.3.5, 13.3.2.1.1, 8.4.1.1, 9.7.5, NFPA 25, 1998 Edition;
2-2.1.1* Sprinklers shall be visually inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged or loaded, or in the improper orientation.

Based on observation and staff interview, the facility failed to ensure window curtains were flame retardant in 1 of 6 smoke compartments. The findings were:

Observation on 5/15/12 at 1:15 PM showed the two window curtains in room #310 did not have flame retardant documentation attached to them. Review of the housekeeping records showed there were not records for these curtains. At the time of the observation the lead electrician reported all curtains should be purchased by housekeeping with flame retardant documentation or sprayed with a flame retardant solution. He could not explain why the curtains had not been noticed and removed or sprayed with a flame retardant solution during the monthly security inspections.

Based on observation and staff interview, the facility failed to ensure the eye wash station was operational. The findings were:

Observation of the lab eye wash station on 5/15/12 at 11:20 AM showed the activation handle was taped closed with clear packing tape. At the time of the observation the lab technician reported the handle was secured shut because the handle had been accidentally activated and water was released all over the floor because of back drainage from the floor drain.

Based on observation and staff interview, the facility failed to ensure oxygen cylinders were restrained in 1 of 6 smoke compartments. The findings were:

Observation on the oxygen storeroom on 5/15/12 at 10:05 AM showed nine "E" cylinders, five "D" cylinders, and eight "B" cylinders were free standing and unrestrained. Further observation showed there were not enough racks for the cylinders in the room. At the time of the observation the lead electrician reported it was the responsibility of the certified nursing assistants to maintain the oxygen cylinders. He could not explain why the staff had not requested more holding racks when they saw the current racks were full.

Reference, NFPA 101, 2000 Edition, 19.3.2.4, NFPA 99, 1999 Edition, 8-3.1.11.2 (h);
4-3.5.2.1 (b) 27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observation and staff interview, the facility failed to ensure extension cords did not replace permanent fixed wiring in 3 of 6 smoke compartments. The findings were:

Observation of the electrical system on 5/15/12 between 10 AM and 12 PM showed extension cords were used in the following locations:
a. The space heater in office #710
b. The microwave oven in office #710
c. The fan in the mail room
d. The coffee pot in office #515
On 5/15/12 at 10:53 AM the lead electrician reported the electrical system was not routinely inspected to ensure prohibited electrical adapters were not used. He also reported staff members have been in serviced not to use extension cords.

Reference, NFPA 101, 2000 Edition, 19.5.1, 9.1.2, NFPA 70, 1999 Edition;
400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls ...
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces